target 8 clawbacks

Share:

Related Story

COLUMBIA – Patients may be spending more on copays for their prescriptions than the actual cash price those drugs would cost. Pharmacists call it a clawback, and it could be costing you extra money that your insurance company is profiting from.

KOMU 8 News received documents from Missouri pharmacists showing some insurance companies have set copays dramatically higher than what people could pay if they paid the cash price.

“A patient is charged a specific fee based on their insurance company, and they pay that copay and the pharmacist provides a service. The problem is some of the copays are exceeding what the actual cash price of the drug is,” said Ron Fitzwater, the CEO of Missouri Pharmacy Association.

Pharmacists often can't offer up your options

Patients might think when they are buying medication at a pharmacy, there are three parties involved: Them, the pharmacy and your insurance provider.

But sometimes there's a fourth party, whose role could be difficult to understand, and pharmacists are not allowed to tell patients about it.

When people go to the pharmacy to buy their medication, their copay is a type of insurance payment where the insured pays a specified amount, and the insurer pays the remaining costs.

Fitzwater said pharmacists can often tell when a drug is offered at a lower price. The problem is pharmacists are not allowed to tell patients about their options under a “gag order.”

It's part of their contract with Pharmacy Benefit Managers, or PBMs, according to the pharmacists KOMU 8 News talked to.

A PBM acts as a middle man between insurance companies and pharmacies. It handles the prescription drug part of health insurance plans on behalf of the insurer.

Pharmacists submit claims to the PBM, which then tells the pharmacy how much to charge each patient.

Examples: Insurance companies pocketing $21-48 per prescription

The examples some Missouri pharmacists provided KOMU 8 News show Cigna is known to clawback, as is Catalyst Rx.

Here is one example from Cigna: A patient paid a copay of about $68 for their generic ADHD medicine, Dexmethylphenidate.

However, the cash price for the drug is only about $50. Cigna pocketed $21.80 from the pharmacy and customer. At the end of the transaction, the pharmacy only got about $46 back. The math is tough to figure out - it doesn't all just simply add up - because there are a lot of factors at play. But the receipts pharmacists from around the state provided clearly showed what was happening.

“It appears that a good part of the clawback that is going back to the PBM is the burden of the patient. It costs the patient more,” pharmacist Ann Bromstedt said.

And chances are, the patient doesn't know its happening.

“You will pay maybe a higher price than what you were prepared to pay in the form of a copay. So, it is not recognizable to you as the consumer or as the patient,” she said.

Fitzwater said pharmacists are required to collect the copay set by the insurance company. After a patient pays, the PBM comes in and takes the difference between what the patient actually paid (in the form of copay) and what is reimbursed to the pharmacist.

He said this is done “under the guise that it’s saving dollars.”

Here is an example from Catalyst Rx: A doctor prescribed a patient Amox/K Clav to treat a bacterial infection. The copay was about $67, but, according to the pharmacist, the cash price is only $19.

The consumer could have paid about four times less money than they did. In this case, the PBM pocketed about $48.

Generic Tamiflu has a cash price of about $85. In this example, the patient would have saved about $30 dollars if they chose not to pay the $115 copay. The PBM clawed back about $49.

Pharmacies are also losing money

Clawbacks are often seen with generic drugs and should be a flag for a patient to price check, according to Bromstedt.

“If it is a generic drug, and it’s a co-pay that seems out of bounds or seems higher than what you are used to paying, say the year before, then you should ask the question: ‘is this higher than cash price? Or what is my cash price?’,” Bromsedt said.

And it’s not always just costing the patient more. The pharmacy takes hits as well.

Bupropion Hcl is used to treat depression. In this example, the patient was charged a $35.55 copay, but the PBM clawed back $22.38. This resulted in a $0.39 loss for the pharmacy.

This is not just an issue in Missouri. A previous investigation done by FOX 8 in New Orleans revealed customers of United Health Care, Cigna and more are seeing clawbacks.

Following this initial investigation, there have been countless lawsuits against insurance companies for the practice.

KOMU 8 News wanted to see what the problem looked like here in mid-Missouri.

Currently, 12 states have laws against the practice of clawing back money or allow pharmacists to be transparent with patients when it comes to payment options.

Missouri House Bill 1542 addresses clawbacks and pharmacists’ ability to be transparent with patients.

“It does talk about the gag orders and most specifically the clawbacks provision and would allow pharmacists to share information. Then, the patient can make a decision if they want to run it through their insurance or pay a cheaper amount,” Fitzwater said.

Fitzwater said the pharmacy association believes the patient at least ought to have the information, but pharmacists cannot share it.

“You know they have to do it based on what the insurance company dictates and, often times, they are not allowed to talk to patients about the difference in the cost,” he said.

Bromstedt said the pharmacist is often the last person a patient sees in the health care process.

“They get discharged from the hospital, they come to the pharmacy with a bunch of prescriptions and we fill them. They have questions, and we answer their questions. So, that is a resource for them,” she said. “And for us to be as open and honest as possible is really a good thing and to their benefit.”

Fitzwater said PBMs are a necessary part of the process, but they have strayed away from their original intent.

“Somebody has to keep record of that so, when the pharmacist puts the patients’ data into the system, they know if they have coverage, what the co-pay is, what physicians they’ve been to,” Fitzwater said.

Customers can ask for lower prices - and pharmacists can give cash cost

He said PBMs were essentially started as a way to help with the transaction process.

“They got to the point where the transaction fees weren’t enough to sustain the business model the way they wanted to so they began looking at other ways where they could make revenue off of that data stream," Fitzwater said.

So now, Fitzwater said, some PBMs sustain their business models by over-charging patients, which is "far outside the original intent" of the system.

He said if the patient asks about a cheaper price, pharmacists have the power to share the information. The pharmacists have the power to re-run a purchase as cash.

“The PBMs are sophisticated enough they watch those metrics. If a pharmacist is backing enough claims out of their system then they assume that the pharmacist is sharing information outside of their contract,” he said.

One insurance company responds: Committed to 'affordable solutions'

KOMU 8 News reached out to Cigna and the PBM associated with Catalyst Rx (Optum Rx) for comment.

Cigna sent the following statement:

"Cigna is committed to offering customers and clients affordable solutions to support improved health while containing both drug and total medical costs. A pharmacy should charge Cigna customers the lowest price available under their plans. We encourage pharmacists to share all options with customers as they struggle to manage the rising costs of prescription drugs."

Optum Rx has not yet responded.

Rep. Lynn Morris, R-Nixa, the sponsor for House Bill 1542, said he expects it to make it to the Senate in mid-April and said he is hopeful it will pass.

KOMU 8 wants to know if this has happened to you. Please send us your examples.

Look up your medication using this search tool

Below, you can use our search tool to look up commonly-prescribed medications that have had insurance clawbacks listed in recent lawsuits.